Technical Approach Determines Inflammatory Response after Surgical and Transcatheter Aortic Valve Replacement

Abstract

ObjectiveTo investigate the periprocedural inflammatory response in patients with isolated aortic valve stenosis undergoing surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) with different technical approaches.Material and MethodsPatients were prospectively allocated to one of the following treatments: SAVR using conventional extracorporeal circulation (CECC, n = 47) or minimized extracorporeal circulation (MECC, n = 15), or TAVI using either transapical (TA, n = 15) or transfemoral (TF, n = 24) access. Exclusion criteria included infection, pre-procedural immunosuppressive or antibiotic drug therapy and emergency indications. We investigated interleukin (IL)-6, IL-8, IL-10, human leukocyte antigen (HLA-DR), white blood cell count, high-sensitivity C-reactive protein (hs-CRP) and soluble L-selectin (sCD62L) levels before the procedure and at 4, 24, and 48 h after aortic valve replacement. Data are presented for group interaction (p-values for inter-group comparison) as determined by the Greenhouse-Geisser correction.ResultsSAVR on CECC was associated with the highest levels of IL-8 and hs-CRP (p<0.017, and 0.007, respectively). SAVR on MECC showed the highest descent in levels of HLA-DR and sCD62L (both p<0.001) in the perioperative period. TA-TAVI showed increased intraprocedural concentration and the highest peak of IL-6 (p = 0.017). Significantly smaller changes in the inflammatory markers were observed in TF-TAVI.ConclusionSurgical and interventional approaches to aortic valve replacement result in inflammatory modulation which differs according to the invasiveness of the procedure. As expected, extracorporeal circulation is associated with the most marked pro-inflammatory activation, whereas TF-TAVI emerges as the approach with the most attenuated inflammatory response. Factors such as the pre-treatment patient condition and the extent of myocardial injury also significantly affect inflammatory biomarker patterns. Accordingly, TA-TAVI is to be classified not as an interventional but a true surgical procedure, with inflammatory biomarker profiles comparable to those found after SAVR. Our study could not establish an obvious link between the extent of the periprocedural inflammatory response and clinical outcome parameters.

Type II Minimal‐Invasive Extracorporeal Circuit for Aortic Valve Replacement: A Randomized Controlled Trial

“…Elevated levels of IL-6 as part of the systemic inflammatory response syndrome have shown to predict outcome and mortality (3,27). In this study, IL-6 levels did not return to baseline and reached the highest level at 24 h in the MiECC group, which may indicate that post-procedural IL-6 release continues beyond 48 h as already demonstrated in another trial by our group while using a type II MiECC setup (28). There are conflicting results regarding this cytokine response in CPB (6).…”

Infections after transcatheter versus surgical aortic valve replacement: mid-term results of 200 consecutive patients

“…However, in addition to the amount of inflammation, a persistent elevated inflammatory marker seems to have a negative association with outcomes including mortality (17). In agreement with earlier reports, we also observed a peak level of CRP after TAVI on the third postoperative day (14,28). In comparison to CRP and PCT, IL-6 showed a significant difference on the immediate postoperative course with significant higher values in the SAVR-group.…”

“…The main explanation of this finding is the presence or absence of cardiopulmonary bypass activating the inflammatory pathway (26), which is a known fact that cardiac surgery with cardiopulmonary bypass activates a systemic inflammatory response that is associated with adverse outcomes (27). These results are similar to the results of Erdoes et al who reported a significant activation of various inflammatory pathways in invasive procedures (e.g., SAVR) in comparison to less invasive procedures (e.g., TAVI) (14). However, in addition to the amount of inflammation, a persistent elevated inflammatory marker seems to have a negative association with outcomes including mortality (17).…”

“…Although, infectious complications after TAVI have not been widely and timely investigated, only few investigators reported such results (9)(10)(11)(12), other investigators examined the inflammatory response after those procedures (13,14). Therefore, we aimed to examine infectious outcomes within the hospital stay, as well as the cumulative infections up to 2-year in a group of consecutive patients presenting with AS and undergoing either TAVI or conventional SAVR.…”

Pre- and post-surgical evaluation of the inflammatory response in patients with aortic stenosis treated with different types of prosthesis

“…However, even after the surgical procedure, the inflammatory state persists in almost half of the patients [ 7 ]. However, recently, it has been proposed that the technical approach determines the inflammatory response after surgical and transcatheter aortic valve replacement [ 8 ].…”